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World J Gastroenterol. Jan 28, 2016; 22(4): 1711-1720
Published online Jan 28, 2016. doi: 10.3748/wjg.v22.i4.1711
Non-invasive assessment of liver fibrosis: Between prediction/prevention of outcomes and cost-effectiveness
Cristina Stasi, Stefano Milani
Cristina Stasi, Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
Stefano Milani, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, 50134 Florence, Italy
Author contributions: Stasi C designed the review, wrote and revised the manuscript; Milani S critically revised the manuscript for important intellectual content and has given final approval of the version to be published.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Cristina Stasi, MD, PhD, Department of Experimental and Clinical Medicine, Largo Brambilla 3, University of Florence, 50141 Firenze, Italy. cristina.stasi@gmail.com
Telephone: +39-55-7947922 Fax: +39-55-7947922
Received: July 27, 2015
Peer-review started: July 30, 2015
First decision: September 9, 2015
Revised: September 26, 2015
Accepted: December 12, 2015
Article in press: December 14, 2015
Published online: January 28, 2016
Processing time: 176 Days and 17 Hours
Abstract

The assessment of the fibrotic evolution of chronic hepatitis has always been a challenge for the clinical hepatologist. Over the past decade, various non-invasive methods have been proposed to detect the presence of fibrosis, including the elastometric measure of stiffness, panels of clinical and biochemical parameters, and combinations of both methods. The aim of this review is to analyse the most recent data on non-invasive techniques for the evaluation of hepatic fibrosis with particular attention to cost-effectiveness. We searched for relevant studies published in English using the PubMed database from 2009 to the present. A large number of studies have suggested that elastography and serum markers are useful techniques for diagnosing severe fibrosis and cirrhosis and for excluding significant fibrosis in hepatitis C virus patients. In addition, hepatic stiffness may also help to prognosticate treatment response to antiviral therapy. It has also been shown that magnetic resonance elastography has a high accuracy for staging and differentiating liver fibrosis. Finally, studies have shown that non-invasive methods are becoming increasingly precise in either positively identifying or excluding liver fibrosis, thus reducing the need for liver biopsy. However, both serum markers and transient elastography still have “grey area” values of lower accuracy. In this case, liver biopsy is still required to properly assess liver fibrosis. Recently, the guidelines produced by the World Health Organization have suggested that the AST-to-platelet ratio index or FIB-4 test could be utilised for the evaluation of liver fibrosis rather than other, more expensive non-invasive tests, such as elastography or FibroTest.

Keywords: Stiffness; Serum markers; Liver fibrosis; Hepatitis C virus; Public health

Core tip: The results of several studies have shown that non-invasive methods are becoming increasingly precise in predicting non-significant and advanced liver fibrosis, thus reducing the need for liver biopsy in a relevant number of patients. However, when both serum markers and transient elastography values fall, liver biopsy may be still needed. Recently, the guidelines for the screening, care, and treatment of hepatitis C virus infected patients produced by the World Health Organization suggested that the AST-to-platelet ratio index or FIB-4 test could be used for the evaluation of liver fibrosis rather than other, more expensive non-invasive tests in a resource-limited setting.